Free California Birth

							State of California – Health and Human Services Agency                                                                   Department of Health Care Services




                                                                                                                                                              Case No:
                                                                                                                                                                           County fills out this box
Request for California Birth Record
Medi-Cal can ask for a birth record for people born in California — for free!

                                                             Today’s date:      Month:             Day:                 Year:
 Here’s how:
 • Fill out this form. Type         Name of person filling out this form:       First:             Middle:              Last:
   or print neatly. You
   may use the
   information from a                  Whose birth record do you want?
   copy of a birth                         Name on birth certificate:           First:             Middle:              Last:
   certificate to complete
   this form.                          If this person was adopted, write
                                                          adopted name:         First:             Middle:              Last:
 • Take or mail your
   completed form to                                                   Sex:        Male   Female
   your local social
                                                             Date of birth:




                                                                                                                                                              Case Name:
   services office.                                                             Month:             Day:                 Year:
 • If you have difficulty                        City and County of birth:      City:              California county:
   filling out this form,
   call your local social                         Mother’s maiden name:         First:             Middle:              Last:
   services office.
 We may not be able to                                     Father’s name:       First:             Middle:              Last:
 get the birth record you
                                        Birth Certificate # (if you know it):
 are asking for. If this
 happens, you must
 provide other proof of                Name of next person whose birth
 citizenship.                                         record you want:          First:             Middle:              Last
 If we get the birth record
 you are asking for, you               If this person was adopted, write
 must still provide proof                                 adopted name:         First:             Middle:              Last
 of identity.
                                                                       Sex:        Male   Female
 The county social services
 office needs the information                                Date of birth:     Month:             Day:                 Year:
 requested to search for
 a California birth record to                    City and County of birth:      City:              California county:
 prove citizenship. You do not
 have to provide this                             Mother’s maiden name:         First:             Middle:              Last:
 information. But if you do not,
 the county may not be able to                             Father’s name:       First:             Middle:              Last:
 find the birth record.
                                        Birth Certificate # (if you know it):
If you need more than two birth records, fill out another form.

DHCS 0004 (06/07)